Lessons Learned, City Prepares for a Resurgence of Swine Flu

Patients in May at Maimonides Medical Center in Brooklyn, where flu plans for the fall are being readied.Credit
Evan Abramson for The New York Times

As New York City braces for a second wave of swine flu this fall, health officials are making plans to carve space out of hospitals, clinics and other buildings to screen people before they can overwhelm emergency rooms.

Hospital and city officials said in interviews that the biggest surprise from the swine flu that swept the city last spring was the surge of visits to emergency rooms by people, especially children, sick with the flu and by a far larger number of people fearing they had it.

A major focus of planning for the fall, officials say, is to avoid being swamped by a similar, possibly bigger, demand for emergency room services. Some hospital officials are advocating putting out daily swine flu bulletins — modeled after announcements on alternate-side parking or lottery numbers — about issues like when to seek treatment.

“I think we were a little surprised at how many people were coming to emergency rooms,” said the city’s health commissioner, Dr. Thomas A. Farley. “And the emergency rooms handled them — it wasn’t a major problem, but it was a problem.”

In planning for the spring outbreak — part of what the World Health Organization called a global pandemic — the city’s experts thought a lot about providing beds and equipment like ventilators for severely ill patients admitted to hospitals, Dr. Farley said. Still, he added, “the thought that there would be large numbers of people in emergency rooms hadn’t been well thought through, so that’s one thing we need to address.”

The virus is still circulating, though in drastically reduced strength, health officials said, and it may continue to circulate at low levels throughout the summer. Flu levels in the city are nearly twice the norm for this time of year, down from 10 to 12 times higher than usual in late May.

But officials expect by September or October to be dealing with another round of seasonal flu combined with the swine flu, known as H1N1. They are watching the Southern Hemisphere, which is now going through its flu season, to try to determine whether the H1N1 virus will return in a more virulent form.

“If you look at the history of new strains of influenza which have appeared on the scene in the past 100 years,” Dr. Farley said, “almost all of them have had a second wave. It doesn’t necessarily occur within the next six months; it might occur a couple of years later. But almost all returned.”

So many people went to hospitals fearing they had swine flu that the city’s ability to confirm cases through laboratory testing was overwhelmed. The phenomenon led epidemiologists to begin talking of “influenza-like illness,” which added an abbreviation to the public’s vocabulary: I.L.I.

On May 25, the worst day of the spring outbreak, 2,500 people visited emergency rooms in the city complaining of influenza-like illness, said Dr. Don Weiss, a city epidemiologist. The number on the same day last year was 150.

From May 15 to June 15, the worst monthlong period of the outbreak, 44,678 people complaining of flulike illness visited the city’s emergency rooms, compared with 4,267 the year before. Total visits in that period for all reasons rose to 428,059, from 325,135.

But in an indication of the large numbers of what doctors call the “worried well,” only 40 to 50 people a day were hospitalized during the worst stretch of that month, records show.

To a large degree, health officials say, the level of fear rose with publicity about deaths and school closings. Visits to emergency rooms began to rise sharply on May 16, the day after the first news reports that an assistant principal in Queens had been hospitalized with swine flu. The assistant principal, Mitchell Wiener, died on May 17, and another spike in hospital visits followed.

A second person, a woman in her 50s from Queens, died with swine flu on May 24. Emergency room visits peaked the next day.

Susan C. Waltman, general counsel for the Greater New York Hospital Association, a trade group, said that to control such panic, hospitals were eager to develop a public messaging system. But she said officials were still unsure how such a system would work.

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Although the health department began gradually posting detailed charts, graphs and instructional material about swine flu on its Web site last spring, the public seemed mostly unaware of that resource, Ms. Waltman said, and instead got information from news reports.

“It’s nobody’s fault,” she said. “But the reaction was that people flooded emergency departments. There was a major consumption of resources that didn’t need to occur.”

Dr. Steven J. Davidson, chairman of the emergency department at Maimonides Medical Center in Brooklyn, said the hospital was developing a mobilization plan for staff members from all over the hospital, so emergency room doctors and nurses would not bear the brunt of an influx of patients, as they did in the spring.

As of July 7, 909 New Yorkers had been hospitalized with swine flu and 47 had died, a fraction of the 1,000 deaths in New York attributed to influenza each year. City officials estimate that 7 percent to 10 percent of New Yorkers, or 580,000 to 830,000 people, had contracted the H1N1 virus, but most had only mild symptoms. A seasonal flu virus is usually contracted by 5 percent to 20 percent of the population.

City officials are planning for the possibility that they will have to ration or prioritize vaccinations, because it is unlikely, they said, that they will receive enough for everyone.

Beyond the question of quantity, there may be issues of psychology. If both seasonal and swine flu are circulating, people will be advised to take vaccines for both. But many people resist being vaccinated, and there is a chance that the H1N1 vaccine could require two doses, making the public persuasion more difficult.

Dr. Farley and others said the experience in the spring had left the city in good shape for the fall. The city was criticized by some parents and politicians as lacking transparency in its decisions to close schools and as waffling over how much to disclose about the underlying health conditions of those who had been hospitalized or died. But Dr. Farley said the city had constantly adapted its policies as information about the severity of the virus changed.

New York’s was the first major outbreak after Mexico’s, he said, and it came when public health officials believed that the virus could be highly lethal.

Dr. Farley said it was hard to determine whether closing schools had been medically justified. The pressure to close them from parents, teachers and politicians in some neighborhoods, particularly in Queens, was intense. But Dr. Farley said the health department had not responded to political pressure.

“I think it made sense at the time,” he said of the closings. “We can’t say whether it slowed transmission within that school. It might or might not have.”

The city is considering, in a worst case, measures like canceling big gatherings and staggering work hours, said Dr. Isaac B. Weisfuse, the city’s deputy health commissioner for disease control, who has been studying the flu pandemic of 1918.

Dr. Weisfuse said that during that outbreak, there was a spike in flu infections and deaths in Philadelphia within several days of a parade to support the country’s effort in World War I. “You can see the pictures from that parade with people very closely packed into the sidewalk watching soldiers march by,” he said. “So in retrospect, you can say they should have canceled the parade.”

In consultation with the Metropolitan Transportation Authority, the health department has concluded that shutting down mass transportation would probably cause more problems, like leaving hospital workers unable to get to work, than it would solve. But Dr. Weisfuse said he expected many people would walk or drive to work if the flu became severe. He said he thought staggered working hours, tried in 1918, might be a good idea, though he added that he was not sure it would work.

A version of this article appears in print on , on Page A15 of the New York edition with the headline: Lessons Learned, City Prepares for a Resurgence of Swine Flu. Order Reprints|Today's Paper|Subscribe